Exploring the determinants of mental health, wellbeing, and lifestyle in 8–11 year old children with type 1 diabetes and their healthy counterparts in Kuwait

Type 1 diabetes is a chronic disease with an early onset, but little is known about its psychological effects in middle childhood. The present study was the first to explore the relationship between mental health, wellbeing, and lifestyle of 8–11 years old children with Type 1 diabetes and their parents, and a healthy comparison group. A total of 200 parent-child dyads were recruited in diabetic clinics and from primary schools in Kuwait. Both groups completed a series of behavioural and physical assessments relating to health, wellbeing, and lifestyle. A significant relationship was found between higher Body Mass Index (BMI) and poorer mental health, including low academic self-esteem, depression, and anxiety, in the diabetes group. This group had significantly higher mean scores in mental health problems, and lower scores in wellbeing, compared with control group. Both groups had poor dietary habits and low levels of physical activity. Unlike previous studies, no differences were found between parents’ mental health for children with Type 1 diabetes and parents of the control group. Although elevated problem scores on a variety of indices remained within normal range, the pattern of results indicates that children with diabetes would profit from early screening and preventative intervention to reduce the likelihood of psychological and behavioural difficulties later on.


Introduction
Type 1 diabetes is an immune-associated disease caused by the destruction of islet ß cells in the pancreas, usually leading to absolute insulin deficiency [1][2][3]. It is a life-changing condition that involves daily glucose monitoring, insulin therapy, and carbohydrate counting [4]. Poor disease management and inadequate glycaemic control can be serious, leading to short-and long-term complications that affect children's quality of life [5]. Even with good management, there is often an increase of body mass index (BMI) compared to children without Type 1 diabetes [6], which is especially significant in the context of increasing rates of childhood overweight and obesity worldwide. Kuwait has the largest percentage of overweight children,

Procedure
All study procedures were granted ethical approval by Bangor University (UK), Kuwait Ministry of Health, and Kuwait Ministry of Education.
In the paediatric clinic, children and their parents were selected by a nurse and approached during their regular visits. The nurse asked the parents whether they would be interested in participating in a research study while in the waiting room prior to their consultation with the doctor. If they agreed to participate, the nurse took them to a meeting room provided by the hospital; this ensured anonymity and privacy. The researcher provided a written consent form and an information sheet for parents to complete before participating. Parents and children were asked to complete measures related to mental health, well-being, and lifestyle. The researcher was available to assist if necessary, and to clarify or rephrase questions for the children. Height, weight, and blood glucose measurements were taken from children's pre-existing records, from the clinic. The questionnaires took less than an hour to complete in all cases. Parent and child dyads were thanked for their participation but no incentives or gifts were offered.
For the control group, we collected the data from four schools chosen by the Ministry of Education. The parental questionnaires were sent home with the child for parents to complete,

Measures
Measures were chosen for their suitability for primary school aged children, widespread use in previous research, and because they were validated and/or showed good internal consistency. They were translated from English to Arabic except for the Coppersmith Self-Esteem Inventory-School Form, The Child Behavior Checklist, The World Health Organization Five Wellbeing Index, and the Strengths and Difficulties Questionnaire, which were already available and validated in Arabic. The measures were translated by a professional from English to Arabic and back to English again; this forward-and back-translation procedure provided an accurate translation of the measures [28]. All the Arabic scripts were also checked by the researcher who is a native Arabic speaker. Fig 1 shows the measures used in the present study. We have administered a battery of questionnaires to parents, asking about their own mental health and parenting, and also about their children's mental health, wellbeing, and lifestyle (including sleep quality, dietary habits, and physical activity). We have also asked children to provide answers about their own mental health (including anxiety, depression, and disordered eating), self-esteem, and coping skills.

Supporting information
Supporting information file contains (i) full descriptions of each measure, subscales, and scoring; (ii) Chronbach alphas obtained for each measure; and (iii) descriptive statistics for all measures.

Preliminary analysis and decision rules
Exploratory data analysis techniques were performed to identify the range, mean, and standard deviation of Child Self-Completed Measures, Parent-Completed Child Measures, and Parent-Completed Self-Report Measures (S2 Table in S1 File). Variables that were found to score higher than ±2 for skew and kurtosis were investigated with non-parametric tests [29], because they did not meet the requirements of normality, linearity, or parametric assumptions. When parametric assumptions were met, one-way ANOVA, independent samples t-tests, Pearson's r product moment correlations, and hierarchical (or linear) regressions were employed. When parametric assumptions were violated, Mann-Whitney U and Spearman's Rho tests were used.
Chi-squares were performed with crosstabs to identify any differences in the parent and child demographic variables for the diabetes and control group. None were identified, meaning that the samples for each group were well matched. The additional findings related to diabetes management (insulin injection or insulin pump) and BMI classifications (e.g., overweight and obese) are presented in the appropriate section.
Each set of inferential tests also included the corresponding effect size calculation when necessary (e.g., Cohen's d, Cohen's f-squared, eta-squared, and post-hoc power analysis). The raw scores for the Child Behaviour Check List subscales were analysed instead of the T-scored data in accordance with Pandolfi, Magyar, and Dill [30] and Holmes et al. [31], who established no differences in the findings reported from using the raw scores in the analysis as opposed to the T-scores. In addition, the T-scored data for the RCADS was also analysed in this study [32].
The analyses were exploratory in nature but we have considered indices of mental health as outcome variables where appropriate. Chronbach alphas obtained for each measure in the present study and descriptive statistics for all measures are presented in S1 File. There were no missing data for any of the participants. The findings are presented in three sections for: (i) diabetes group; (ii) control group; and (iii) comparisons between the scores for the diabetes and control group. Only statistically significant results are listed in each section.

Diabetes group
Independent samples t-tests were carried out to identify differences between blood test scores (HbA1c) when comparing children with managed vs. unmanaged diabetes according to The International Society for Paediatric and Adolescent Diabetes (ISPAD, 2018) criteria. The managed group (n = 46) had an HbA1c of less than 7.5%, and the unmanaged group (n = 54) had an HbA1c of 7.5% or more. A significant difference was found between the groups when comparing their scores for parental shame; the parents in the unmanaged group (M = 58.48, SD = 8.84) reported being more manipulative than those in the managed group (M = 54.52, SD = 9.63), t(98) = -2.14, p < .05, d = 0.40 (small-medium effect size).
BMI percentiles for diabetes group. A Pearson's r correlation was conducted to identify the relations between the children's Body Mass Index (BMI) percentiles and study measures. As shown in Table 3, a number of significant positive correlations were found to exist between the scores for BMI percentile; eating disorder survey body dissatisfaction, T-scored RCADS panic disorder, T-scored RCADS depression, and T-scored RCADS general anxiety scores. A negative correlation was also found to exist between BMI percentile and eating disorder scores items 1-7, parental DASS-21 stress scores, and children's self-esteem academic score.
BMI classifications for diabetes group. The BMI scores for the diabetes group were classified into four main categories: underweight; healthy weight, overweight, and obese. The underweight group was excluded from the analysis (n = 1). Children whose BMI was classified as obese scored higher on eating disorders survey body dissatisfaction; and T-scored RCADS panic disorder, general anxiety, and sleep awake earlier. Overweight children scored higher on T-scored RCADS obsessive compulsive. Interestingly, children whose BMI was classified as healthy weight were found to be scoring higher on the eating disorder survey items 1-7 than those who were either overweight or obese (see Table 4).
Mental health and wellbeing variables for the diabetes group. A Pearson's r bivariate correlation was conducted to identify the relations between children's mental health and wellbeing scores (see Table 5). A number of significant negative correlations were found to exist between the child's wellbeing and T-scored RCADS social phobia, T-scored RCADS depression, T-scored RCADS generalised anxiety, and eating disorder survey body dissatisfaction scores. This demonstrates that the elevated scores for (non-clinical) measures of social phobia, depression, generalised anxiety, and eating disorder survey body dissatisfaction may be associated with poorer wellbeing in children with diabetes. A positive correlation was also found to exist between the parents' wellbeing and children's self-esteem school academic scores.
Eating disorder survey binge eating scores were inversely correlated with coping avoidance, coping wishful thinking, and sleep morning wake up scores, indicating that children with poorer coping and sleep-related problems had elevated disordered eating behaviour.

PLOS ONE
Social phobia scores showed a significant negative correlation with coping avoidance, and academic self-esteem scores; children with an elevated social phobia appeared to engage in fewer avoidance techniques and had lower academic self-esteem. A significant inverse relation between separation anxiety and self-esteem total scores was also observed.
Higher scores for the raw CBCL withdrawn depressed subscale showed significant positive relation with parental shame, and with parents feeding perceived responsibility scores. There were also significant inverse relations between the raw CBCL anxiety/depressed and coping emotional reaction scores, and coping subscale 3 score.
The effects of diabetic management type. The scores for the main variables were inspected by diabetes management type to identify any differences on the main variables. Children whose diabetes was managed with a insulin pump scored higher on self-esteem general and social than those whose diabetes was managed by insulin injection. Children whose diabetes was managed by insulin injection scored higher on eating disorder survey binge eating and T-scored RCADS separation anxiety. The parents of the children who were managed by insulin pump registered more HFS behaviour scale related problems than those parents whose child was managed by insulin injection (see Table 6). It is worth noting that the children with diabetes in this study were primarily managed by insulin injection.
Regression analysis for diabetes group. Regression analysis were run to establish further the relations between the predictors and child mental health outcome variables after controlling for the effect of diabetes management type. Tolerance and Variance Inflation Factors (VIF) were examined to identify any collinearity issues in the models. This is important as it means the independent variables do not influence one another too much. Therefore, it can be identified to what extent each independent variable influences the dependent variables, separately. Tolerance varies between 0 and 1.00, for example, when the value is greater than 1.00 it

Control group
BMI percentile control group. A Pearson's r correlation was conducted to identify the relations between the BMI percentiles and the main study variables scores. As shown in Table 8, all eating disorder survey subscale scores were found to correlate with BMI percentile: items 1-7 score, binge eating score, and body dissatisfaction score. In other words, higher weight status was associated with higher disordered eating indices. However, a negative correlation was found between BMI percentile and peer problem scores from the strengths and difficulties questionnaire (SDQ).
A Spearman's Rho correlation was conducted on the scores for BMI percentiles and lifestyle variables scores. As shown in Table 9, a significant negative correlation was found between BMI percentiles and sleep waking during the night, and positive correlations with the amount and frequency of physical activity at the weekend. Surprisingly, higher weight status was associated with less interrupted sleep and more activity in the control group.
BMI classifications for control group. In a similar manner to the diabetes group, the BMI scores for the control group were reclassified into four categories; the underweight group

PLOS ONE
Mental health, wellbeing, and lifestyle in children with Type 1 diabetes was excluded from the analysis (n = 3). The healthy weight children scored higher on eating disorder survey items 1-7 than the other BMI classifications; obese children scored higher on eating disorder survey body dissatisfaction. Both these finding are in keeping with the diabetes group. A noticeable difference to the diabetes group is that the obese children in the control group were also scoring higher on eating disorder survey binge eating, T-scored RCADS major depression, and lower for raw CBCL anxiety problem. Surprisingly, the healthy weight children in the control group were found to be scoring the highest on CBCL anxiety problem and sleep: waking during the night (see Table 10).
Mental health and wellbeing variables in the control group. A Pearson r bivariate correlation was conducted to investigate the relations between mental health and wellbeing scores (see Table 11). A negative correlation was found to exist between wellbeing and T-scored RCADS depression scores. Children's higher T-scored RCADS obsessive-compulsive scores correlated with higher parental shame and parental child weight. However, raw CBCL anxious depressed subscale scores were found to share a significant negative correlation with shame and bedtime scores.
Unsurprisingly, children who reported higher scores for eating disorder survey binge eating also reported higher body dissatisfaction. However, eating disorder survey items 1-7 scores had a significant negative correlation with body dissatisfaction scores and binge eating scores. Unexpectedly, eating disorder survey items 1-7 scores were positively correlated with total self-esteem, academic self-esteem, and general self-esteem scores.

Comparisons between the diabetes and control group
Comparison data analyses were carried out with 100 children with Type 1 diabetes, 100 control children, and their parents. Table 12 shows the differences in the variable scores by group.
Differences for diabetes and control group by BMI classification. A one-way ANOVA with six groups was used to identify how children classified by their BMI as healthy weight, For eating survey binge eating scores, those in the control group classified as obese scored higher than the other BMI classifications in either the diabetes or control group, F(5,190) = 6.69, p < .001, η 2 = 0.15 (large effect). They also scored higher for body dissatisfaction, F (5,190) = 9.35, p < .001, η 2 = 0.20 (large effect). No other differences on main variables were identified (p>.05).
Parent variables. Parents in the control group had significantly lower mean scores for feeding responsibility and had less monitoring over the feeding of their children. Parents of children with Type 1 diabetes had significantly lower mean scores on parenting sum, parenting  laxness, and parenting verbosity than parents in the control group. However, there were no significant differences between the parents of each group on their reported levels of external shame, mental health, and wellbeing (p>.05). Child variables. Children with Type 1 diabetes had significantly lower mean scores for general self-esteem, social, home parents, school academic, and total self-esteem than the control group. There were no differences between the two groups on eating disorder survey body dissatisfaction. Children with Type 1 diabetes had significantly lower mean scores for the eating disorder survey items 1-7, while the control had significantly lower mean scores for eating disorder survey binge eating.
The state of wellbeing in the children with Type 1 diabetes was less positive than that of the control group. Compared with the control group, the children with Type 1 diabetes had significantly higher mean scores of T-scored RCADS subscales, raw CBCL subscales, and SDQ emotional symptoms subscale. Significantly lower mean scores in sleep habits were observed in children with Type 1 diabetes group, while the control group had significantly lower mean scores of sleep waking during night and sleep morning wake up.
Lifestyle variables. The control group had significantly lower median scores for lifestyle food, fruits in the past 7 days, in the last week, and the average daily portions in their diet compared to children with Type 1 diabetes. However, children with Type 1 diabetes reported significantly lower median scores of vegetable meals in the last 24 hours, less non-core food for the past 7 days, less sweetened beverages in 24 hours, and a daily portion of non-core foods, compared to the control group. Children with Type 1 diabetes had significantly higher median scores than the control group when comparing the frequency of physical activities. However, it should be noted that, in both cohorts, diet was relatively poor and levels of activity low (see Table 12 and S1 File).

Discussion
The present study was the first to investigate mental health, wellbeing, and lifestyle factors in young children with Type 1 diabetes and their healthy counterparts in Kuwait. The findings demonstrate the connections between a range of lifestyle and self-evaluative variables such as eating habits, self-esteem, shame, and peer interactions, with children's mental health and wellbeing. In most part, our results align with the findings reported in the existing literature from samples with broader age range, older children, and those from different cultures. However, some of the results were surprising.

Main findings for the diabetes group
The main findings for the diabetes group analysis showed that some differences were due to HbA1c grouping (managed or unmanaged); BMI percentile and classification (e.g., obese or overweight), and diabetes management type (insulin injection or pump). For HbA1c, the only notable findings were for the unmanaged group, where parents reported an increase in manipulativeness and the children consumed less water than the managed group. More findings were associated with BMI percentile and classification; three positive correlates were found to exist between T-scored RCADS mental health and BMI percentile scores. BMI percentile scores also shared one negative correlate (items 1-7) and one positive correlate (body dissatisfaction) with the eating disorder survey scores. These correlational findings are further supported by the one-way ANOVAs. Obese children were found to be scoring higher on body dissatisfaction and the panic and anxiety indices of the RCADS. Those who were overweight scored higher on the RCADS obsessive compulsive index. This pattern of correlates and ANOVA analyses clearly demonstrate the relations between BMI, mental health, and disordered eating patterns in the diabetes group. Other notable findings include inverse relations between BMI percentile and parental stress and children's self-esteem academic. We also found that healthy weight children scored higher on items 1-7 of the eating disorders survey and that obese children were waking earlier than the other BMI classifications.
Differences on self-esteem, mental health, and disordered eating indices were observed when investigating the role of diabetes management type. Children who were managed by insulin injection (n = 84) were found to score lower on self-esteem general and social and higher on T-scored RCADS separation anxiety and eating disorder survey binge eating. Parents of children managed by insulin pump (n = 16) recorded higher scores for the HFS behaviour scale than those managed by insulin injection, implying that they may be engaging in more avoidance behaviour to reduce their child's hypoglycaemic risk [33].
In summary, the elevated scores on the RCADS mental health and eating disorder survey items within the diabetes group were associated with differences in BMI percentile, BMI classification, diabetes management type, and with poorer self-esteem, coping behaviour, and sleeprelated problems. This conclusion is supported by the regression analyses that show both binge eating and T-scored RCADS separation anxiety are predicted by a combination of being maintained by insulin pump injection, self-esteem, coping behaviour, and sleep-related problems. Broadly, our findings correspond to the existing literature: Melnyk et al. [34] and Halfon et al. [35] reported a correlation between scores for depression, low self-esteem, school problems, number of missed school days, and a high BMI. A negative relationship found to exist with binge eating, coping avoidance, and sleep habits in our study is consistent with the findings reported by Burt et al. [36]. Poor wellbeing in children with diabetes may be associated with depression, general anxiety, social phobia, and body dissatisfaction. A similar association was also reported by de Wit et al. [9], who found that children with Type 1 diabetes reported higher social phobia scores and lower academic self-esteem and avoidance technique scores; whereas those with higher levels of anxiety reported low self-esteem. These finding are also in keeping with those reported by Ayla et al. [37] and Yemane et al. [38].
In our sample, the scores for mental health and disordered eating indices that were elevated within the diabetes group did not yet fall into a clinical range. Nevertheless, our findings imply that the screening and assessment of younger children with Type 1 diabetes may be needed to identify those who may profit from early (preventative) intervention.

Main findings for the control group
Our study was the first to explore the relationship between lifestyle, wellbeing, and mental health indices of healthy primary-school age children from an Arab country.
The BMI percentiles for the healthy control group shared positive correlations with three disordered eating indices (eating disorder survey items 1-7; binge eating and body dissatisfaction), as previously reported in the literature by Munkholm et al. [39]. These findings differ to those for the diabetes group, which showed an inverse relation between BMI percentile and eating disorder survey items survey 1-7. An additional difference observed is the inverse relation between the strengths and difficulties questionnaire (SDQ) peer problems scores and BMI percentile for the control group, whereas no relations between SDQ subscale scores and BMI percentile were observed in the diabetes group.
An unexpected finding was the positive relations between BMI percentile and the amount and frequency of physical activity in the control group. This may be due to the number of overweight and obese children in each group (control n = 52 and diabetes n = 45), or because the scores for physical activity were lower than expected for this age-range in each group. This finding needs to be replicated in another study to further elucidate the relations between BMI and physical activity.
The main findings in relation to BMI classification for the control group are the higher scores for obese children on eating disorder survey binge eating and T-scored RCADS major depression. They may be at risk of engaging in emotional or loss of control eating to regulate depression related symptoms [40].
In general, the pattern of BMI classification for the controls is identical to that for the diabetes group when it comes to eating disorder survey items 1-7 and body dissatisfaction. An unexpected finding is the scores for healthy weight children on the raw CBCL anxiety problem scale and sleep waking during the night. This was contrary to the findings reported by Kanellopoulou et al. [41] who found that poor sleep patterns and sleep duration are associated with higher weight status. Although these scores are elevated in our sample, they do not fall within a clinical range. The same also holds for the healthy weight children's positive pattern of correlates for disordered eating (items 1-7) and self-esteem indices (total, academic and general) and the negative relations between wellbeing and T-scored RCADS depression scale.
The present study also identified the links between child mental health and other variables such as parental shame, behavioural difficulties in children, their sleep habits, and self-esteem. As was expected, better wellbeing was found to be related to fewer behavioural and emotional problems, including depressive symptoms [42]. By contrast, differences were observed between previous studies and the current study, as children with higher scores for disordered eating reported higher scores for self-esteem [43].

Comparisons between diabetes and control group
We found that the control group scored higher on all the disordered eating variables (e.g., binge eating) than the diabetes group, Troncone et al. [44] suggested that it is most likely the result of the increased attention that children with Type 1 diabetes are forced to pay to their bodies, both in terms of function and size (weight loss/gain), and the knowledge of the value of nutrition, exercise may exacerbate a person's self-consciousness, irrespective of BMI classification.
In our sample, diabetes group scored lower on measures of: self-esteem; eating disorder survey items 1-7, wellbeing, T-scored RCADS subscales (all), raw CBCL subscales (most), and sleep habits. Lower levels of self-esteem in the diabetes cohort could be linked to how a young person sees their own efficacy in the home, at school, and in other situations [41,45]. Their higher mental health problem scores may put them at greater risk of experiencing depression, anxiety, and social phobia related problems in the future. Our findings are in line with other published studies: they could be associated with patient frustration with the differences between themselves and other children, the need to take daily insulin shots, lifestyle changes as a result of long-term disease management, and poor understanding of their condition among parents [11,46]. Increased family conflict and low self-esteem are also likely to be linked to poor wellbeing [9]. Children with Type 1 diabetes have been reported to have more sleep disturbances, such as night-time waking, compared to their healthy counterparts, due to hypoglycaemia or parents' night-time caregiving practices [46,47].
Surprisingly, some indices showed that fruit and vegetable consumption was higher in the diabetes group and they consumed less non-core food (e.g., snacks), less sweetened beverages, and had higher physical activity levels than the control group. This would be good news, because healthy pattern makes blood sugar easier to control and could prevent obesity and any long-term related complications, such as cardiovascular disease and stroke. Excessive weight has been found to enhance the body's resistance to insulin, resulting in increased insulin needs and more weight gain [26]. Unfortunately, it needs to be noted that most children's consumption of healthful foods was extremely low in both groups, and their Median BMI was high. The same can be said about their levels of physical activity. There are probably cultural reasons for this pattern. With respect to the diabetes group, it had previously been reported that diabetic teenagers tend to avoid physical activity due to fear of hypoglycaemia [48], even though physical activity can lower HbA1C levels and improve quality of life [49,50]. Overall, we consider that healthy lifestyle interventions promoting fruit and vegetable consumption and physical activity would benefit both cohorts.
Some variations in parental behaviours were also observed. Parents in the control group scored lower on the child feeding related variables (e.g., feeding responsibility) than the parents of children with Type 1 diabetes; this may be due to added responsibilities in the latter group related to diabetes management. The opposite trend was seen for parenting related problems (e.g., laxness), with parents of children with Type 1 diabetes scoring lower. Many previous studies have shown that parents of children with diabetes show symptoms of anxiety, depression, and stress compared to control groups [18,19]. However, our study did not find any differences in the mental health and wellbeing scores for parents of young children with Type 1 diabetes and the control group. This could be the result of the higher sensitivity to moral values, and the higher levels of prosocial behaviours exhibited among Kuwaiti parents, as Kuwait is considered a religious country [51]. It may be that relative wealth and traditional extended family structure act as protective factors for these parents. However, there is also a possibility that parents did not want to disclose any mental health issues, as indicated by limited research regarding mental health in the Middle East, as well as the social and cultural stigma surrounding this topic [23,52]. Almazeedi and Alsuwaidan [53] claim that stigma makes people less likely to disclose negative behaviours related to poor mental health or wellbeing. Therefore, they are less likely to seek treatment or more information regarding these issues. In addition, religion, shame on the family, and a lack of community support can also act as barriers to mental health disclosure and support in countries such as Kuwait [53].

Strengths, limitations, and recommendations
The strengths of our research include: examining the relations between mental health, wellbeing, and lifestyle factors (previously not used in a single sample) in diverse cohorts that reflect the population but were nevertheless well matched at the outset on a range of demographic variables; recruiting 8-11 year old primary-aged children (rather than older children or a very broad range of ages, as was typical in the existing literature); looking at parent-child dyads; and reporting the result from an under-researched population.
We also note some limitations to the conclusions that can be drawn from the study. This research relied mainly on self-report measures, which can be prone to biases in both children and adults [35]; however, the alternatives would have been both impractical and, in some cases, arguably less reliable. We asked the children to complete some of the questionnaires; similar data collection methods to ours have often been used in the existing literature with this age group and measures [54][55][56]. However, it is possible that some of our findings may have been different had the parents been asked to assist their children. Some of our measures were translated into Arabic for this study, and not previously validated in this sample; however, the Cronbach alpha scores indicated their suitability. Finally, we have not assessed pubertal status of the children although this variable may affect their psychological functioning and recommend that this should be done in follow-up research.
Overall, our findings indicate that children with Type 1 diabetes, and their parents, could benefit from targeted psychosocial support. Given that a range of potential issues have been identified in a primary age cohort, such support should be offered early to prevent development of more serious problems later on.